If You Have Studied at Edge Hill Before, Please State Your Student ID Number

If you have studied at Edge Hill before, please state your Student ID Number:

* Denotes a required field

1. Personal Details
*Surname: / Previous Surname
(if applicable):
*First Names: / *Title (Mr, Mrs, Miss, Ms, etc):
*Gender: / *Date of Birth:
*Email : If you are providing a school email address, please provide a secondary email address also.
*Home Address:
*TRN: (Teacher Reference Number, DfE number or GTC number)
*Postcode:
*Mobile: / Home telephone:
*Country of Permanent Residence: / *Country of Birth:
*Nationality:
Where did you hear about us?
2. Context Details
*School name: / Type of school (please tick as appropriate):
□ Primary
□ Secondary
□ Early Years
□ Special
□ Pupil Referral Unit
□ Secure Unit
Setting (please tick as appropriate):
□ Local Authority Maintained □ Academy
□ Independent
□ Other (please indicate)
*School URN:
*School address:
*Postcode:
*School telephone:
*School government region: (e.g. East Midlands, etc)
*Local Authority Area:
*Current School Role: / *Current Ofsted Category:
*Approximate School Roll:
3. Equal Opportunities Monitoring Data Edge Hill University uses this information to monitor our equal opportunities and widening participation policies. This information is used solely for statistical purposes. If you prefer not to provide this information, please tick ‘Decline information’.
Disabilities
*Do you have a disability? □ Yes □ No □ Decline information
Are you in receipt of Student Disability Allowance? □ Yes □ No □ Decline information
What is the nature of your disability? ______
Do you have Dyslexia? □ Yes □ No □ Decline information
Ethnic Origin
*Please choose from the terms printed here the one which you feel most describes your ethnic origin:
□ 10. White
Black or Black British
□ 21. Caribbean
□ 22. African
□ 29. Other / Asian or Asian British
□ 31. Indian
□ 32. Pakistani
□ 33. Bangladeshi
□ 34. Chinese
□ 39. Other Asian background / Mixed
□ 41. White/Black Caribbean
□ 42. White/Black African
□ 43. White Asian
□ 49. Other Mixed background
□ 80. Other Ethnic background
□ Decline information
4. Dietary Requirements
Do you have any dietary requirements? □ Yes □ No
If yes, please detail ______
5.Programme Options
Please choose the module/s you would like to complete :
o  Leading Change for improvement
o  Leading an Effective Team and Developing Staff
o  Succeeding in Middle Leadership
·  Cost - £250 per module
6. Programme Location
Please indicate your preference for the area in which you would like to undertake the programme:
West Oxfordshire :
□ West Oxfordshire / Other :
7.Invoicing
*Name of organisation or individual to be invoiced
Address for invoice (if different from above)
Postcode
Email Address
Telephone Number
8. Cancellation/Non attendance Policy
Should you be unable to attend a session on the programme you are required to notify the School Leadership Team as soon as possible via telephone on (01257) 517128 or via email at .
Reimbursement of module fees will not be provided for non-attendance.
9. Declaration
I confirm that I have read and understand the conditions of the Cancellation/Non-Attendance Policy as detailed above. I confirm that the information given on this form is correct. By signing this form I agree to abide by the policies and procedures of Edge Hill University and understand that the institution may take action against individuals who contravene them.
Overseas Students: Edge Hill University reserves the right to inform the UK immigration authorities if the student ceases to attend classes. Overseas students must inform the International Office of any changes relating to attendance/registration at the University.
Signature:. ______Date: ______
10. Approval
An important part of participating in the programme is the support of your Headteacher. This is particularly important if your school is financing your place on the programme.
Please ask your Headteacher to sign your registration form to confirm their support for your place on the programme and their acknowledgement of our Cancellation/Non-Attendance Policy.
If obtaining your Headteacher’s approval will delay our receipt of your registration form, please provide their contact details in the box below and the School Leadership Team will contact your Headteacher directly.
Headteacher Declaration
I verify that the participant is working within an appropriate role, fully support their application to this leadership programme and will provide mentor support to the participant while on the programme.
I have read and understand the implications of the Cancellation/Non-Attendance Policy as detailed in section 9 above.
Name of Headteacher:
Email address:
Signature:. ______Date: ______

Please return your registration form via email to: Thank you for choosing to register with our MLMP programme. We will now be in touch via email to outline your next steps.

MLMP